development and implementation of a diabetes management

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Doctor of Nursing Practice Papers School of Nursing

8-2019

Development and Implementation of a DiabetesManagement Flow Sheet in a Primary CarePractice: A Quality Improvement Project.Lace N. HoustonUniversity of Louisville, [email protected]

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Running head: DIABETES MANAGEMENT FLOW SHEET 1

DEVELOPMENT AND IMPLEMENTATION OF A DIABETES MANAGEMENT FLOW

SHEET IN A PRlMARY CARE PRACTICE:

A QUALITY IMPROVEMENT PROJECT

by

Lace N. Houston

Paper submitted in partial fulfillment of the

requirements for the degree of

Doctor of Nursing Practice

University of Louisville

·SchoolofNursing

Date Finalized

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Date

080519

Si~ature DNP Project Committee Member

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Date

Signature Program Director Date

g-7 -/ qSignature Associate Dean for Academic Affairs Date

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DIABETES MANAGEMENT FLOW SHEET 2

Acknowledgments

I would like to acknowledge Beverly Williams-Coleman DNP, APRN, Celeste Shawler, PhD,

PMHCNS-BC, University of Louisville School of Nursing faculty, family, Carolyn, Chandler,

and Laila, Amanda York, RN, Sharon Murphy, BSN, Laura Ernst, BSN, and Cheryl Herre, MS,

Dedra Hayden, DNP, APRN, Diane Riff, DNP, APRN, Karen Zabel APRN, Julie Buckman,

APRN, Tiffany Gardner, APRN, Tina Yuan, MD, for their inspiration, support, and contributions

to the development and implementation of this DNP project and journey.


Dedication

I dedicate this manuscript to my parents, Carolyn and in loving memory of Anthony, children,

Chandler and Laila, sisters Toni and Erin, and family, Ramon, Raymond, and Candace Nieves,

for their encouragement, motivation, and blessings.

INSERT AN ABBREVIATED TITLE HERE 4

Table of Contents

Manuscript Title Page ............................................................................................................1

Acknowledgments..................................................................................................................2

Dedication ..............................................................................................................................3

Manuscript Abstract ...............................................................................................................5

Manuscript…………………………………………………………………………………..6

References ..............................................................................................................................21

Appendix A: Theoretical Framework ..................................................................................26

Appendix B: Plan-Do-Study-Act ..........................................................................................27

Appendix C: Documentation Flyer .......................................................................................28

Appendix D: Responsibility Matrix ......................................................................................29

Appendix E: Chart Audit Form.............................................................................................30

Appendix F: Strength, Weakness, Opportunity, and Threat Analysis ..................................31

Appendix G: Diabetes Management Flow Sheet ..................................................................32

Appendix H: Clinical Practice Guidelines ............................................................................33

Appendix I: Staff Evaluation Survey ....................................................................................34

Appendix J: Paired T-test Results .........................................................................................35

Appendix K: Diabetes Management Flow Sheet Results .....................................................36

Appendix L: Staff Evaluation Survey Results ......................................................................37


Abstract

Primary care practices that do not utilize electronic medical records (EMR) could pose difficulty

in adhering to clinical guidelines for diabetic patients. Diabetes flow sheets are a one page

document that includes current practice guideline recommendations for easy access of results to

promote comprehensive care. The main objective of this project was to promote adherence to

diabetes guidelines with the use of a diabetes flow sheet for providers that do not utilize an EMR.

Plan-Do-Study-Act was the design for this project. A total of 50 medical records were randomly

selected at a primary care office. A pre and post-implementation of the diabetes flow sheet was

audited for documentation of clinical practice guidelines (CPG). A post implementation

evaluation was administered for the feasibility of the flow sheet and for evaluation. The results of

the diabetes flow sheet to promote better adherence to CPG were significant. The total scores of

the pre and post documentation mean (M) and standard deviation (SD) increased significantly

from pre-implementation (M = 11.67, SD = 1.06) to post-implementation (M = 13.67, SD =

1.34), t (42) = 8.26, p<.0000. The mean differences in pre-implementation and post-

implementation of diabetes flow sheet was (M = 2.00, SD = 1.59) with a 95% CI ranging from

[1.51 to 2.48]. Maintaining a diabetes flow sheet in the front of the paper medical record is

imperative so PCPs can utilize the process of the flow sheets to establish adequate care

management for health outcomes for type 2 diabetes.

Key words: diabetes management; diabetes flow sheet; clinical practice guidelines;

diabetes algorithm; adherence to guidelines


Development and Implementation of a Diabetes Management Flow Sheet in a Primary Care

Practice: A Quality Improvement Project

Type 2 diabetes mellitus (DM) is a chronic medical condition that impacts the health

status of populations medically and financially. More than 30 million Americans have diabetes

(about 1 in 10), and 90% to 95% of them have type 2 diabetes (Centers for Disease Control and

Prevention [CDC], 2018). Diabetes is the 7th leading cause of death in the United States (CDC).

As of 2017, Kentucky is ranked 7th in the United States for diabetes (State of Obesity, 2018). The

total estimated cost of diagnosed diabetes in 2017 is $327 billion, including $237 billion in direct

medical costs and $90 billion in reduced productivity (American Diabetes Association [ADA],

2018).

Diabetes is the number one cause of kidney failure, lower limb amputations and adult

onset of blindness (CDC, 2018). With more than 84 million U.S. adults with prediabetes, 90% of

them do not know they have it (CDC, 2018). These statistics demonstrate the necessity for

diabetes management with the use of CPG. An aim for greater adherence to current diabetes

management is imperative for the health and well-being of the U.S. population.

Background

Diabetes is defined as a complex group of diseases marked by high blood glucose due to

the body’s inability to make or use insulin adequately (National Committee for Quality

Assurance [NCQA], 2018). Diabetes has associated comorbidities of cardiovascular disease,

stroke, hypertension, obesity, kidney disease, nerve damage, and foot and eye complications. In

the last 20 years, the number of adults diagnosed with diabetes has more than tripled as the

American population has aged and become more overweight or obese (CDC, 2018). Type 2


diabetes most often develops in people over age 45, but more and more children, teens, and

young adults are also developing it (CDC, 2018).

Risk factors that contribute to diabetes include: race, smoking, overweight/obesity,

physical inactivity, high blood pressure, high cholesterol, and hyperglycemia (CDC, 2018).

Modifiable risk factors include: low socioeconomic status, barriers to healthcare access,

underutilization of healthcare resources, lower rates of insurance coverage, and lack of health

literacy (Brown, Garcia, Zuniga, & Lewis, 2018). According to the National Diabetes Statistic

Report (2017), overall prevalence was among American Indians/Alaska Natives (15.1%), non-

Hispanic blacks (12.7%), and people of Hispanic ethnicity (12.1%) than among non-Hispanic

whites (7.4%) and Asians (8.0%) (CDC, 2017). The State of Obesity (2018), revealed the adult

obesity rate was at or above 35% in seven states and at least 30% in 29 states. Proper diabetes

management is essential to control blood glucose, reduce risks for complications and prolong life

(NCQA, 2018). With support from health care providers, patients can manage their diabetes with

self-care, taking medications as instructed, eating a healthy diet, being physically active and

quitting smoking (NCQA, 2018).

According to Kentucky Diabetes Prevention and Control Program [KDPCP) (2017),

Kentucky has the 4th highest diabetes mortality rate in the U.S. As of 2017, Kentucky’s current

adult diabetes rate is 12.9 % and ranked 7th in the U.S. (State of Obesity, 2018). It is estimated

that one in three Kentucky adults are prediabetic (37% or 1.1 million) (KDPCP, 2017). At the

current pace, projected cases of diabetes in 2030 is estimated at 594,058 (66%) (State of Obesity,

2018).

National organizations such as ADA and NCQA have addressed the management of the

prevalence of diabetes and its comorbidities with CPG and recommendations. The American


Diabetes Association has established Standards of Medical Care in Diabetes 2019. The Standards

include the most current evidence-based recommendations for diagnosing and treating adults and

children with all forms of diabetes (ADA, 2019). The National Committee for Quality Assurance

(2018) created standards and guidelines to measure performance. The practice guidelines and

recommendations for diabetes care are components that can be integrated into a diabetes flow

sheet. The flow sheets are utilized in healthcare practices that do not use EMR. Diabetes flow

sheets are one page forms that tracks lipids, cholesterol, glycated hemoglobin (A1C), urinalysis,

blood pressure, fundal examination, weight and body mass index (BMI) and blood pressure

medications (Williams & Curtis, 2015).

Problem Statement

Hashmi and Khan (2016) reported that the management of diabetes mellitus is often

difficult to coordinate and requires structured plans to adequately control this multisystem

disease and prevent associated morbidity. In addition, these authors reported implementing

structured plans has been shown to improve overall diabetes management. However, evidence

has shown inadequate adherence of the recommended diabetes guidelines among healthcare

providers for diabetes care management (Hashmi & Khan, 2016). Consequently, for primary care

practices that do not utilize EMR could pose difficulty in adhering to clinical guidelines for

diabetic patients. According to de Belvis, Pelone, Biasco, Ricciardi, & Volpe (2009), although

algorithms exist for diabetes care, lack of information systems often fail to achieve predefined

standards. Also, evidence has shown that improved data monitoring systems are important to

achieve good quality of diabetic care by physicians (Hashmi & Khan, 2016). Thus, a tracking

tool like a diabetes flow sheet can assist with the management of diabetes care. The one page

https://www.sciencedirect.com/topics/medicine-and-dentistry/glycated-hemoglobin

https://www.sciencedirect.com/topics/medicine-and-dentistry/urinalysis

https://www.sciencedirect.com/topics/medicine-and-dentistry/chlorphenamidine

https://www.sciencedirect.com/topics/medicine-and-dentistry/body-mass-index


form can assist healthcare providers with updated results of type 2 DM management without

having to search though the chart to obtain health status results.

The primary care clinic was selected for this project related to the identification of

evidence that supports the inconsistent clinical practice guideline adherence. For example, the

lack of EMR, which evidence has shown that improved data monitoring systems are important to

achieve good quality of diabetic care by physicians (Hashmi & Khan, 2016). There are currently

no interventions or tools used at this clinic to support the adherence of CPG. Due to the increased

prevalence of DM, it is important to evaluate the screening patterns of diabetes associated health

problems in primary care clinics (Albarrak et al., 2018). Physicians and primary care clinics have

been noted to use clinical guidelines inconsistently and variably (Hashmi & Khan, 2016;

Moharram & Farhat, 2008; Patasi & Conway, 2008). A 208.6 million dollar cost incurred by

people with diabetes in a primary care office (American Diabetes Association, 2018).

Furthermore, research has shown that more of type 2 diabetes care conditions are managed in

primary care clinics (Albarrak et al., 2018; de Belvis et al., 2009; Patasi & Conway, 2008).

Theoretical Framework

The Knowles Adult Learning Theory served as theoretical framework for this project (see

Appendix A). This framework was chosen because of the education, knowledge, and experience

bases of teaching adults about new or existing concepts. Malcolm Knowles (1913-1997), an

American educator, first used the term Andragogy in the United States (Knowles, Holton, &

Swanson, 2012). Andragogy is defined as a set of core adult learning principles that apply to all

adult learning situations (Knowles et al., 2012). Four assumptions are specific for adult learners

such as: changes in self-concept, role of experience, readiness to learn, and orientation to

learning of problem centered (Knowles, 1973). The adult learners were the PCPs and all office


staff for their participation in the education and evaluation of this project. The changes in self-

concept involved increasing self-direction of described tasks during the project. The role of

experience involved using their past experiences as a resource for learning new ideas. Readiness

to learn involved the participants timing to learn new concepts based on their current role or

position. Lastly, problem centered focused on the importance of the process improvement with

the diabetes flow sheet that led to enhancement of health outcomes of diabetes care.

Setting and Organizational Assessment

The clinical agency is an urban family medicine practice that provides primary care

services to approximately 400 patients monthly. Services include, chronic disease management,

preventative care, sick visits, and annual checkups. The primary care clinic is a private practice

with a physician with 32 years of experience and a nurse practitioner with a year and a half of

experience. This clinic accepts patients with private insurance, Medicaid, Medicare, and no

health insurance. Lab services are located next door to the facility. The facility is located in an

urban area in Southeastern United States. Permission by the facility for the implementation of the

project was granted on March 11, 2019.

Purpose

The purpose of this project was to develop and implement a diabetes flow sheet to

include the components of the CPG set forth by the ADA 2019 and NCQA 2018 for providers

that do not utilize an EMR. The aim is to measure the adherence of the providers with the

diabetes flow sheet. The use of the diabetes flow sheet will increase the provider’s adherence of

CPG, assessment for close monitoring, and adjustments to care.


Intervention

The intervention for the project was based on the plan-do-study-act (PDSA) design and

was conducted in four phases (See Appendix B). The intervention team consisted of a primary

care physician, nurse practitioner, medical assistant, and a front office receptionist. A meeting

was scheduled for an in-service of the project that detailed the background, evidence, process,

training of diabetes flow sheet, and evaluation.

Phase One

The DNP student obtained baseline data from a pre-implementation chart review. This

included a simple random sample of 50 medical records of diabetic patients during the

measurement year of January 1, 2018 to December 31, 2018. Data was abstracted from the

medical record to include: (a) height, weight, BMI; (b) blood pressure; (c) HbA1C; (d)

nephropathy (spot urine test for albumin or protein, or angiotensin converting enzyme [ACE]

inhibitor or angiotensin receptor blocker [ARB] medication prescribed) or currently being taken;

(e) eye exam; and (f) foot exam (ADA, 2019; NCQA, 2018).

Phase Two

The Primary care providers (PCPs), a medical assistant, and the receptionist at the front

office were provided with a 15 minute PowerPoint in-service on significance of diabetes in

Kentucky, the utility and feasibility of the diabetes flow sheet, and the CPG for diabetes.

Documentation reminder flyers were posted in the triage area, front desk, and all patient rooms

to remind staff and PCPs of the importance of diabetes flow sheets (see Appendix C). Placement

of reminders in relation to decision making about the care practices are essential (Melnyk &

Fineout-Overholt, 2015). The DNP student obtained a list of patients with a scheduled

appointment and a diagnosis of type 2 diabetes from the front office receptionist (see Appendix


D for responsibility matrix). The front office receptionist and medical assistant retrieved the

charts of the type 2 diabetic patients that were scheduled for the week. The DNP student placed a

diabetes flow sheet in the front of the chart. In the event of walk in patients, the front office

receptionist made a copy of the diabetes flow sheet and placed it in the patient’s chart. The

medical assistant documented on the diabetes flow sheet of the patient’s results of height, weight,

BMI, blood pressure, and any available lab values during triage. The PCP reviewed the results

and assessed the patient for further evaluation or treatment. The PCP documented any needed

referrals. The medical assistant made arrangement for any necessary referrals.

Phase Three

Once a week, the DNP student checked the medical records of patients seen in the

practice to see if the diabetes flow sheet was completed. The DNP student transposed the data

entered on the diabetes flow sheet to the chart audit form (see Appendix E). A post-

implementation chart review was conducted. Data was based on the ADA 2019 and NCQA 2018

guidelines and recommendations to include: (a) height, weight, BMI; (b) blood pressure; (c)

HbA1C; (d) nephropathy (spot urine test for albumin or protein or ACE or ARB); (e) eye exam;

and (f) foot exam (ADA, 2019; NCQA, 2018).

Phase Four

After the completion of the data abstraction, the DNP student evaluated the results of the

documentation process. This included, the baseline data from the pre-implementation chart

review, data from the flow sheet during the post-implementation chart review, and any

documented referrals. In addition, a staff evaluation survey was administered to the participants

of the project for feasibility of the diabetes flow sheet, the process, and feedback. Dissemination

of the results of the project and evaluation survey will be provided to the staff and PCPs.


Strength, Weakness, Opportunities, Threats

A Strength, Weakness, Opportunities, and Threats (SWOT) analysis demonstrated areas

internally and externally that negatively and positively affected the quality improvement project

(see Appendix F). The strength identified was the assistance and support of the primary care

providers and clinical staff for their participation in the project. The weakness identified was the

lack of documentation on the diabetes flow sheet and no use of EMR. The opportunities included

the utilization of the diabetes flow sheet at a reminder for CPG, increase referrals for better

diabetes management, and greater progress monitoring. The threat was identified as the DNP

student inability to visit more frequently to ensure documentation of the flow sheets were

completed.

Participants

The participants of the project and inclusion criteria included (a) primary care physician

(n = 1); (b) nurse practitioner (n = 1); (c) medical assistant (n = 1); and (d) front office

receptionist (n = 1). The exclusion criteria for the project included (a) temporary staff, and (b)

nurse practitioner students. The consent process included a consent form that was presented

during the in-service training. Consent was voluntary with the option to no longer participate at

any point during the project. The office manager was omitted from the project voluntarily. The

University Institutional Review Board (IRB) approval was submitted for approval prior to

implementing the quality improvement project.

Data Collection

A pre-implementation chart review included a random selection of 50 medical records of

diabetic patients during the measurement year of January 1, 2018 to December 31, 2018. This


included the flow sheet measures as baseline data. Data was collected to verify, yes or no that

they were assessed in each medical record.

A post-implementation chart review included 50 random medical records of patients

diagnosed with Type 2 diabetes six weeks after the implementation phase. Data was collected

based on the medical records that contained the diabetes flow sheet. The data from the flow sheet

during the post-implementation chart review was compared to the baseline data from the pre-

implementation chart review.

The data from the staff evaluation survey was collected and analyzed. The questions from

the staff evaluation survey was summed and divided into percentages. Measuring the compliance

usage of the diabetes flow sheet as well as the usefulness was performed during the post-

implementation phase (see Appendix J, K, and L).

Ethical Considerations

The plan for maintenance and security of the data was accessed only in the office. De-

identified data was abstracted from the medical record during the pre and post chart review and

kept in a locked filing cabinet in the office manager’s office. The medical record confidentiality

was protected by the Health Information Portability and Accountability Act of 1996 (HIPAA).

The project data was only accessible to the DNP student.

Referral Plan

If a referral was warranted (specialist, podiatry, optometrist, registered dietitian), the

PCP documented on the flow sheet and provided the medical assistant with the needed

information for the patient referral. A referral is important and necessary in diabetic patients due

to other comorbidities conditions to see any specialist other than primary care physician

(Albarrak et al., 2018).


Measurement

The DNP student implemented the quality improvement project which included

development and implementation of a diabetes flow sheet as a measurement tool (see Appendix

G). The tool is a one page document that consist of recommendations from the Standards of

Medical Care in Diabetes from the ADA 2019 and measurement guidelines from NCQA 2018.

Flow sheets are tools for managing and measuring processes of care, using them increases the

chance of adhering to assessment guidelines (Hahn et al., 2008). The ADA 2019 components

were chosen based on the grading of A or B recommendation and NCQA components were

chosen from the 2018 comprehensive diabetes care (see Appendix H). The A ratings are selected

based on studies from clinical control trials and B ratings are from cohort studies (ADA, 2019).

An evaluation of the quality improvement project was used to evaluate the feasibility of

the diabetes flow sheet (see Appendix I). This survey is descriptive and contains three, five point

Likert style questions from strongly disagree, disagree, neither disagree or agree, agree, or

strongly agree. According to Joshi, Kale, Chandel, & Pal (2015), a Likert scale is a set of

statements or items where participants are asked to show their level of agreement on a metric

scale. Likert style questions were chosen because the scale was devised in order to measure

attitude in a scientifically accepted and validated manner since 1932 (Joshi et al., 2015). The

evaluation contains (a) professional role; (b) did you view the diabetes flow sheets in the chart;

(c) did you complete any components of the diabetes flow chart; (d) how did you find the

usefulness of the diabetes flow sheet; (e) did the diabetes flow sheet save you time; (f) was the

diabetes flow sheet easy to follow; (g) list reasons of why you are or not satisfied; and (h) any

suggestions for improvement.


The medical record review data was analyzed based on descriptive statistics, frequencies,

percentages, and a paired T- test using the Statistical Package for Social Sciences (SPSS).

Results

A total of 50 medical records were audited for the pre-implementation of the diabetes

flow sheet. A total of 43 out of 50 (86%) medical records were audited post-implementation. A

paired samples t-test was conducted to evaluate the documentation of the diabetes flow sheet to

promote better adherence to CPG. The use of the diabetes flow sheet mean increased

significantly from pre-implementation (M = 11.67, SD = 1.06) to post-implementation (M =

13.67, SD = 1.34), t (42) = 8.26, p <.0000, respectively (see Appendix J). The mean differences

in pre-implementation and post-implementation of diabetes flow sheet was (M = 2.00, SD =

1.59) with a 95% CI ranging from [1.51, 2.48], respectively. The magnitude of effect was large

(eta squared = .62).

Intervention Results

A total of 43 out of 50 (86%) medical records were utilized for the post-implementation

chart review. A total of seven out of 50 (14%) of the medical records flow sheets were

incomplete due to no show visits. The measures of the flow sheet resulted, height (100%), weight

(97.7%), BMI (90.6%), blood pressure (97.7%), HbA1C (55.8%), nephropathy (ACE or ARB)

(46.5%), eye exam (53.5%), and foot exam (25.6%) (ADA, 2019; NCQA, 2018). The overall

total scores of the pre and post implementation ranged from 10 points to a maximum of 16 points

for each measure of the flow sheet (see Appendix K). A score of one point was given for “NO”

and two points was given for “YES”. The pre flow sheet total was (N = 50 for 582). The post

flow sheet total was (n = 43 for 588). The referral documentation included three out of 43 (7%)

had eye referrals and one out of 43 (2.3%) had a podiatry referral.


Discussion

Interpretation

The results of the diabetes flow sheet implementation and use were significant for the

adherence of the CPG. The post-implementation results compared to the pre-implementation

results for the nephropathy profile (46.5% vs 44%), foot (25.6% vs 20%), and eye exam (53.5%

vs 36%) showed significant improvement. Unfortunately, the documentation of weight (97.7%

vs 100%), BMI (90.7% vs 98%), and HbA1C (55.8% vs 66%) demonstrated a decrease in

documentation. The DNP student noted during the audit the lack of missing reports such as lab

results in the chart. This hindered the results of both chart reviews. Similar results of the project

were noted with those of Albarrak et al., 2018. The researchers reported the ADA standards

assessment of physical examination, the elements such as height, weight, BMI, and blood

pressure demonstrated above 95.0% compliance to the ADA standards of diabetic care (Albarrak

et al., 2018). Meanwhile, their study showed 40% of eye examinations, compared to 53.5% eye

examinations with the current study. The nephropathy profile only included documentation for

ACE or ARB medication use. The primary care practice did not provide testing for spot urine

test for albumin or protein. The referrals showed a total result of 9.3% for eye and foot

examination referrals. According to Albarrak et al, 2018 a referral is important and necessary in

diabetic patients due to other comorbidities conditions to see any specialist other than primary

care physician. In contrast, only 19.3% of their referrals were documented accordingly to ADA

specifications (Albarrak et al., 2018). Based on the overall staff evaluation survey, the diabetes

flow sheet was found to be useful and easy to follow. There was a variation in the response to

whether the flow sheet saved time. Of those, 25% disagreed, 50% neither agree or disagree, and

25% strongly agreed (see Appendix L). Satisfaction and recommendations showed the flow sheet


focused on the problem, information was all on one sheet, easy to monitor the progress, and

easier to check when preventive visits are due. One suggestion was noted as maintaining flow

sheet on bright colored paper as a reminder.

Unintended Consequences

An unintended consequence occurred during the project. Due to the nurse practitioner’s

schedule, a second in-service was scheduled. Since the medical assistant failed to complete the

flow sheet, the PCP’s felt it was more work on them to complete the form. During that time, the

medical assistant was training medical assistant students. This was a hindrance to the project

because the DNP student had to transpose the remaining data for the duration of the project. This

consequence resulted in the PCP’s perception of more work for the provider. In a similar study,

using flow sheets results in significant improvement in physician adherence, however, may have

difficulty in following numerous and detailed standards of care (Moharram & Farahat, 2008).

Limitations

There were several limitations to this project. First, the timeframe of the project was

limited to six weeks due to PCP schedule, office closings, and provider and staff vacations.

There were two in-services due to the schedules of the physician and nurse practitioner. Second,

the DNP student was limited to weekly visits for the project due to other clinical assignment

arrangements. If the DNP student was able to be present more often, the adherence to the

documentation may have been greater with additional reminders. Third, the flow of the process

and documentation could have been minimal for the PCP’s if there were additional staff to assist

with the documentation of the flow sheet. Fourth, since the office uses paper charting, some of

the medical records did not have the necessary documentation like the lab results. Additional

staff could assist with filing the necessary documents in the medical records for availability.


Implications and Recommendations

This project has been found to be very useful and easy to follow. There are several

benefits of a diabetes flow sheet. The flow sheet will save the PCP time of having to sort through

the medical record for the essential criteria for diabetes care. It can improve documentation and

provision of diabetes care (Moharram & Farahat, 2008). Primary care physicians can have a tool

that is practical and easy to use (Patasi & Conway, 2008). With continued use, the diabetes flow

sheet is sustainable to assist the PCP’s with a constant reminder of diabetes measures to improve

health outcomes. The quality improvement project identified gaps in care that implicated

improvement in diabetes care management. Using the diabetes flow sheet for six months to one

year, would show optimal improvement in guideline adherence. This primary care clinic and

similar facilities could benefit from regular charts audits and continuous education of the staff for

greater adherence to guidelines. Future research is needed to provide more education to

physicians and support staff to improve adherence to CPG. Minimal structured training in basic

diabetes principles, can significantly affect the quality of care and health of patients with

diabetes (Maryniuk, Mensing, Imershein, Gregory & Jackson, 2013).

Conclusion

In conclusion, the quality improvement project has shown significant results of a diabetes

flow sheet for documentation adherence to CPG. The DNP student was able to provide

significant evidence with the use of a diabetes flow sheet for the primary care office that does not

utilize EMR. Clinical practice guidelines such as HbA1c, nephropathy, eye and foot exam

showed minimal increase in documentation. Evidence has also shown that for primary care

practices with no EMR can utilize diabetes flow sheets for efficient processes, adherence to

guidelines, and better health outcomes for the patient. The DNP student was able to implement a


diabetes flow sheet that can assist providers with easy access to results, provide pertinent

information in one place, and engage the patient on the progression of care. A diabetes flow

sheet can be a potential benefit and influence all practices that manage diabetes care without an

EMR. This will allow the provider to set attainable goals for better management of diabetes.


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(2018). Evaluation of diabetes care management in primary clinics based on the

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DIABETES MANAGEMENT FLOW SHEET

26

Appendix A

Knowles Four Principles of Adult Learning (eLearning [Online image], 2018; Knowles, 1973)


Appendix B

Plan Do Study Act (PDSA) Design (The W. Edward Deming Institute, 2018)


Appendix C

Documentation Reminder Flyer


Appendix D

Responsibility and Communication Matrix

Responsibility Communication

Matrix

DNP Student Participants

Time

Audit charts for demographics

& gaps in care

R S 1 Month

Inservice participants on

diabetes flow sheet

R S 15 Minutes

Implementation of project R S 1 Month

Documentation reminders

postings

R S 1 Month

Place diabetes flow sheet in

charts

R/S R/S Weekly for weeks

Documentation of assessments

in diabetes flow chart

S R 6 weeks

Weekly chart audits R S 6 weeks

Implementation of evaluation R S 6 week Post

Implementation

Completion of survey S R 6 week Post

Implementation

Audit charts post

implementation

R S 6 week Post

Implementation

Evaluation of results survey &

diabetes flow chart

R/I S 6 week Post

Implementation

R = Responsible

S = Support

I = Informs


Appendix E

Chart Audit Form

Number Height Weight BMI BP HbA1C Renal profile Eye exam Foot exam


31

Appendix F

Strength, Weakness, Opportunity, Threat (SWOT) Analysis

• DNP student's inability to visit more often to ensure documenation of the flow sheet

• Diabetes flow sheet as reminder of clinical practice guidelines

• Increase referrals

• Progress monitoring

• Lack of documentation on diabetes flow sheet

• No EMR

• Assistance and support of PCP's and clinical staff for their participation

Strength Weakness

ThreatOpportunity


Appendix G

Diabetes Flow Sheet based on ADA 2019 and NCQA 2018 Guidelines

Name Date of Birth Height1

Diabetes Measures Every Visit

Date of Visit

Weight1

BMI1

Blood Pressure1,2

Diabetes Measure Quarterly Visit

Date of Visit

HbA1c: Poor control >9%2

HbA1c: Fair control <8%2

HbA1c: Good control <7%1,2

Diabetes Measure Yearly Visit

Date of Visit

Nephropathy (spot urine test for

albumin or protein or ACE or

ARB)1,2

Random albumin/protein

ACE/ARB (Y or N)

Foot exam (referral)1

Eye Exam (referral)1,2

Adapted from ADA Standards of Medical Care in Diabetes 20191

Adapted from NCQA Comprehensive Diabetes Care 20182


Appendix H

Clinical Practice Guidelines Measures Adapted from ADA 2019 and NCQA 2018

1Adapted from ADA Standards of Medical Care in Diabetes 2019.

2Adapted from NCQA Comprehensive Diabetes Care 2018.

Measures ADA Recommendation 2019

NCQA Guidelines 2018

Height B recommendation

Weight B recommendation

BMI B recommendation

Blood pressure B recommendation1 NCQA2

HbA1C A recommendation1 NCQA2

Nephropathy Profile B recommendation1 NCQA2

Eye examination B recommendation1 NCQA2

Foot examination B recommendation


Appendix I

Staff Evaluation Survey

1. Circle your professional role (select only one)

MD NP MA Front Office Receptionist

2. Did you view the diabetes flow sheets in the charts? Yes No

3. Did you complete any components of the diabetes flow sheet? Yes No

4. Did you find the diabetes flow sheet useful?

Strongly

disagree

Disagree Neither disagree

or agree

Agree Strongly agree

5. Did the diabetes flow sheet save time?

Strongly

disagree


or agree


6. Was the diabetes flow sheet easy to follow?

Strongly

disagree


or agree


7. Please list the reasons why you are/not satisfied with the diabetes flow sheet.

8. Please list any suggestions you have for improving the diabetes flow sheet.


35

Appendix J

Paired T Test Table

Paired T-test Comparison of Mean Documentation Scores before and after Implementation of

Diabetes Flow Sheet

Score

M (SD) t df p

Pre Flow Sheet

Score

Post Flow Sheet

Score

11.67 (1.06)

13.67 (1.34)

8.26 42 <.0000


Appendix K

Pre and Post Diabetes Flow Sheet Score

100 100 100 98

66

44

36

20

100 97.7

90.7

97.7

55.8

46.5

53.5

25.6

2.3 70

20

40

60

80

100

120

Diabetes Flow Sheet

Percentage of Time Measure Was Reported

Pre Flow Sheet Post Flow Sheet


Appendix L

Staff Evaluation Survey Responses

Staff Evaluation Survey

Response Question Score (%)

Did you view the diabetes flow sheet in the chart? 100%

Did you complete any components of the diabetes flow sheet? 50%

Did you find the diabetes flow sheet useful?

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

0%

0%

25%

0%

75%

Did the diabetes flow sheet save time?

Strongly disagree

Disagree


Agree

Strongly agree

25%

0%

50%

0%

25%

Was the diabetes flow sheet easy to follow?

Strongly disagree

Disagree


Agree

Strongly agree

0%

0%

25%

0%

75%

Please list the reasons why you are/not satisfied with the diabetes flow sheet.

Mainly focused on problem Easy to follow

Helps keep records on one sheet Easy to monitor progress

Easy to check when preventive is due More work for the provider

Please list any suggestions you have for improving the diabetes flow sheet.

Maintain a bright color for the flow sheet as a reminder

Note. Responses to staff evaluation survey.

development and implementation of a diabetes management

Documents